Judge Hughes Case app

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Instructions for Optional Application for Federal Employment - OF 612

You may apply for most Federal jobs with a resume, an Optional Application for Federal Employment (OF 612), or other written format. If your resume orapplication does not provide all the information requested on this form and in the job vacancy announcement, you may lose consideration for a job. Type oprint clearly in black ink. Help speed the selection process by keeping your application brief and sending only the requested information. If essential toattach additional pages, include your name and Social Security Number on each page.

For information on Federal employment, including alternative formats for persons with disabilities and veterans preference, contact the U.S. Office ofPersonnel Management at 478-757-3000, TDD 478-744-2299, or via the Internet at www.USAJOBS.opm.gov.

If you served on active duty in the United States Military and were separated under honorable conditions, you may be eligible for veterans preference. Treceive preference, if your service began after October 15, 1976, you must have a Campaign Badge, Expeditionary Medal, or a service-connected disabiliVeterans preference is not a factor for Senior Executive Service jobs or when competition is limited to status candidates (current or former career orcareer-conditional Federal employees).

Most Federal jobs require United States citizenship and also that males over age 18 born after December 31, 1959, have registered with the SelectivService System or have an exemption.

The law prohibits public officials from appointing, promoting, or recommending their relatives.

Federal annuitants (military and civilian) may have their salaries or annuities reduced. Every employee must pay any valid delinquent debt or the agencmay garnish their salary.

Send your application to the office announcing the vacancy. If you have questions, contact the office identified in the announcement.

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Privacy Act Statement

The U.S. Office of Personnel Management and other Federal agencies rate applicants for Federal jobs under the authority of sections 1104, 1302, 3301,3304, 3320, 3361, 3393, and 3394 of title 5 of the United States Code. We need the information requested in this form and in the associated vacancyannouncements to evaluate your qualifications. Other laws require us to ask about citizenship, military service, etc. In order to keep your records in orderwe request your Social Security Number (SSN) under the authority of Public Law 104-134 (April 26, 1996). This law requires that any person doing businewith the Federal government furnish an SSN or tax identification number. This is an amendment to title 31, Section 7701. Failure to furnish the requestedinformation may delay or prevent action on your application. We use your SSN to seek information about you from employers, schools, banks, and otherswho know you. We may use your SSN in studies and computer matching with other Government files. If you do not give us your SSN or any other

information requested, we cannot process your application. Also, incomplete addresses and ZIP Codes will slow processing. We may confirm informationfrom your records with prospective nonfederal employers concerning tenure of employment, civil service status, length of service, and date and nature ofaction for separation as shown on personnel action forms of specifically identified individuals.

Public Burden Statement

We estimate the public reporting burden for this collection will vary from 20 to 240 minutes with an average of 40 minutes per response, including time forreviewing instructions, searching existing data sources, gathering data, and completing and reviewing the information. Send comments regarding the burdstatement or any other aspect of the collection of information, including suggestions for reducing this burden to the U.S. Office of Personnel Management(OPM), OPM Forms Officer, Washington, DC 20415-7900. The OMB number, 3206-0219, is currently valid. OPM may not collect this information and youare not required to respond, unless this number is displayed. Do not send completed application forms to this address. Follow directions provided in thevacancy announcement(s).

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER


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OPTIONAL APPLICATION FOR FEDERAL EMPLOYMENT OF 612

Optional Form

OMB No. 3206-0Form Appr

Section A Applicant InformationUse Standard State Postal Codes (abbreviations). If outside the United States of America, and you do not have a military address,

type or print OV in the State field (Block 6c) and fill in the Country field (Block 6e) below, leaving the Zip Code field (Block 6d) blank.

1. Job title in announcement 2. Grade(s) applying for 3. Announcement number

4a. Last name 4b. First and middle names 5. Social Security Number

6a. Mailing address

6b. City 6c. State 6d. Zip Code

7. Phone numbers (include area codeif within the United States of America)

7a. Daytime

7b. Evening

6e. Country (if not within the United States of America)

8. Email address (if available)

Section B Work ExperienceDescribe your paid and nonpaid work experience related to this job for which you are applying. Do not attach job description.

1. Job title (if Federal, include series and grade)

2. From (mm/yyyy) 3. To (mm/yyyy) 4. Salary

$

per 5. Hours per week

6. Employers name and address 7. Supervisors name and phone number

7a. Name

7b. Phone

8. May we contact your current supervisor? Yes NoIf we need to contact your current supervisor before making an offer, we will contact you first.

9. Describe your duties and accomplishments

Section C Additional Work Experience

1. Job title (if Federal, include series and grade)

2. From (mm/yyyy) 3. To (mm/yyyy) 4. Salary

$

per 5. Hours per week

6. Employers name and address 7. Supervisors name and phone number

7a. Name

7b. Phone

8. Describe your duties and accomplishments

U.S. Office of Personnel Management NSN 7540-01-351-9178 Page 1 of 2Previous edition usable 50612-101 Revised December2


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Section D Education

1. Last High School (HS)/GED school. Give the schools name, city, state, ZIP Code (if known), and year diploma or GED received:

2. Mark highest level completed: Some HS HS/GED Associate Bachelor Master Doctoral

3. Colleges and universities attended. Do notattach a copy of your transcript unless requested.

Total Credits EarnedSemester Quarter

Major(s)Degree (if any),Year Received

3a. Name

City State Zip Code

3b. Name

City State Zip Code

3c. Name

City State Zip Code

Section E Other Qualifications

Job-related training courses (give title and year). Job-related skills (other languages, computer software/hardware, tools, machinery, typispeed, etc.). Job-related certificates and licenses (current only). Job-related honors, awards, and special accomplishments (publicationsmemberships in professional/honor societies, leadership activities, public speaking, and performance awards). Give dates, but do not sedocuments unless requested.

Section F General

1a. Are you a U.S. citizen? Yes No 1b. If no, give the Country of your citizenship

2a. Do you claim veterans preference? No Yes If yes, mark your claim of 5 or 10 points below.

2b. 5 points Attach your Report of Separation from Active Duty(DD 214) or other proof.

2c. 10 points Attach an Application for 10-Point Veterans Preference(SF 15) and proof required.

3. Were you ever a Federal civilian employee? No Yes If yes, list highest civilian grade for the following:

3a. Series 3b. Grade 3c. From (mm/yyyy) 3d. To (mm/yyyy)

4. Are you eligible for reinstatement based on career or career-conditional Federal status? No YesIf requested in the vacancy announcement, attach Notification of Personnel Action(SF 50), as proof.

Section G Applicant Certification

I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete,and made in good faith. I understand that false or fraudulent information on or attached to this application may be grounds for not hiringme or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may beinvestigated.

1a. Signature 1b. Date (mm/dd/yyyy)

U.S. Office of Personnel Management NSN 7540-01-351-9178 Page 2 of 2 Optional FormPrevious edition usable 50612-101 Revised December2

Print Form Save Form Clear Form


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Form W-9 (Rev. 1-2005) Page 4

What Name and Number To Give theRequester

Give name and SSN of:For this type of account:

The individual1. Individual

The actual owner of the accountor, if combined funds, the firstindividual on the account 1

2. Two or more individuals (jointaccount)

The minor 23. Custodian account of a minor(Uniform Gift to Minors Act)

The grantor-trustee 14. a. The usual revocablesavings trust (grantor isalso trustee)

1. Interest, dividend, and barter exchange accountsopened before 1984 and broker accounts consideredactive during 1983. You must give your correct TIN, but youdo not have to sign the certification.

The actual owner 1b. So-called trust accountthat is not a legal or validtrust under state law2. Interest, dividend, broker, and barter exchange

accounts opened after 1983 and broker accountsconsidered inactive during 1983. You must sign thecertification or backup withholding will apply. If you aresubject to backup withholding and you are merely providingyour correct TIN to the requester, you must cross out item 2in the certification before signing the form.

The owner 35. Sole proprietorship orsingle-owner LLC

Give name and EIN of:For this type of account:

3. Real estate transactions. You must sign thecertification. You may cross out item 2 of the certification.

A valid trust, estate, orpension trust

6.

Legal entity 4

4. Other payments. You must give your correct TIN, butyou do not have to sign the certification unless you havebeen notified that you have previously given an incorrect TIN.Other payments include payments made in the course ofthe requesters trade or business for rents, royalties, goods(other than bills for merchandise), medical and health careservices (including payments to corporations), payments to anonemployee for services, payments to certain fishing boatcrew members and fishermen, and gross proceeds paid toattorneys (including payments to corporations).

The corporationCorporate or LLC electingcorporate status on Form8832

7.

The organizationAssociation, club, religious,charitable, educational, orother tax-exempt organization

8.

5. Mortgage interest paid by you, acquisition orabandonment of secured property, cancellation of debt,qualified tuition program payments (under section 529),IRA, Coverdell ESA, Archer MSA or HSA contributions ordistributions, and pension distributions. You must giveyour correct TIN, but you do not have to sign thecertification.

The partnershipPartnership or multi-memberLLC

9.

The broker or nomineeA broker or registerednominee

10.

The public entityAccount with the Departmentof Agriculture in the name ofa public entity (such as astate or local government,school district, or prison) thatreceives agricultural programpayments

11.

Privacy Act Notice

List first and circle the name of the person whose number you furnish. Ifonly one person on a joint account has an SSN, that persons number mustbe furnished.

Circle the minors name and furnish the minors SSN.

You must show your individual name and you may also enter your businessor DBA name on the second name line. You may use either your SSN orEIN (if you have one). If you are a sole proprietor, IRS encourages you touse your SSN.

List first and circle the name of the legal trust, estate, or pension trust. (Donot furnish the TIN of the personal representative or trustee unless the legalentity itself is not designated in the account title.)

Note.If no name is circled when more than one name islisted, the number will be considered to be that of the first

name listed.

Sole proprietorship orsingle-owner LLC

The owner 3

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Part II. Certification

For a joint account, only the person whose TIN is shown inPart I should sign (when required). Exempt recipients, seeExempt From Backup Withholding on page 2.

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxableinterest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

To establish to the withholding agent that you are a U.S.person, or resident alien, sign Form W-9. You may berequested to sign by the withholding agent even if items 1, 4,and 5 below indicate otherwise.

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returnswith the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition orabandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRSuses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide thisinformation to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carryout their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies toenforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

Signature requirements. Complete the certification asindicated in 1 through 5 below.

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2

3

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Judge Hughes Case app